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April 4, 2008 The Centers for Medicare & Medicaid
Services (CMS) issued an article entitled “NPI: Understanding
the Readiness of Other Health Plans, Steps to Facilitate
a Smooth Transition to NPI-Only Billing and More.” It
was posted to the National Government Services Web site
in the “What’s New” section on April 7.
The article stated that the “intent of CR 5243 was
to enable Medicare to appropriately crosswalk a provider
NPI to each of the provider’s subparts through the reporting
of taxonomy codes in the claims. Medicare found that
using taxonomy codes has been unsuccessful in obtaining
a one-to-one match on the crosswalk for those providers
having one NPI tied to multiple OSCAR/ Certification
numbers.
Fiscal Intermediary Standard System (FISS)
Matching Criteria - Currently, FISS uses the following
matching criteria:
- Type of Bill to OSCAR/Certification Number. If
no match on this level it moves to the second level,
- Revenue code to OSCAR/Certification Number. If
no match on this level it moves to the third and final
level,
- Facility ZIP code on the claim - This final level
prompts the systems logic to limit the list of appropriate
OSCAR numbers by matching the facility ZIP code on
the claim against the ZIP code of the master address
in the FISS provider address file.
If after going through the three steps, the system
is still unable to make a valid match, the claim will
suspend with reason code 32105 and the provider will
receive an additional development letter (ADR) requesting
the OSCAR number.
ZIP Code
It is critical that providers ensure they are using
the proper ZIP Code when submitting claims.
The provider ZIP code on claim page 04 must be the same
as the ZIP code that is on the crosswalk file. In some
cases it a matter of using the five-digit ZIP versus
ZIP + four but in most cases it is a totally different
ZIP on the claim than is on the crosswalk file.
Additional Development Request (ADR) Letter
When a provider receives an ADR, the provider needs
to furnish the OSCAR/legacy number for which the claim
should be paid. The ADR must be returned to National
Government Services within 14 business days.
We have received a number of ADRs with medical records
attached. Medical records are not required
for these non-medical ADRs.
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